ML20043H959

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LER 90-024-00:on 900521,T-handle Instrument Isolation Valve Discovered Closed,Resulting in Isolation of Liquid Radwaste Effluent Line Monitor 2R18.Caused by Personnel Error.Valve Added to Tagging Request Info Sys Data base.W/900619 Ltr
ML20043H959
Person / Time
Site: Salem PSEG icon.png
Issue date: 06/19/1990
From: Miller L, Pollack M
Public Service Enterprise Group
To:
NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM)
References
LER-90-024, LER-90-24, NUDOCS 9006270131
Download: ML20043H959 (6)
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U..S. Nuclear Regulatory Commission Document Control Desk c Washington, DC 20555 .

Dear Sir:

' SALEM GENERATING STATION LICENSE NO. DPR-75 DOCKET NO. 50-311 UNIT NO. 2 LICENSEE. EVENT REPORT 90-025-00 This Licensee Event Report is being submitted pursuant to the l requirements of the Code of Federal Regulations 10CFR 'i L -- 50.73 (a) (2) (v) . This report is. required within thirty (30) days'of .!

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" inoperable", either the monitor would have been made operable or Technical Specification 3.3.3.8 Table 3.3-12 Action 26 sample requirements would have been met. The root cause of this event has been attributed to personnel error. The isolation of the 2R18 instrument isolation valve occurred due to an error by Chemistry ,

Department personnel after performing a chemical addition where this valve was required to be isolated. Contributing to this event was procedural inadequacy. The valve alignment verification steps, in the Operations procedure used to control radioactive liquid releases does

'not identify or require verification that the instrument isolation valve is open prior to a release. The Chemistry Department personnel involved in this event have been held accountable. A critique of this event was conducted with all Chemistry Department personnel. The instrument isolation valve has been numbered, 22WR170. The Operations Department release procedure will be revised to include verification that the instrument isolation valve is open prior to making a release. The chemistry addition procedure was reviewed and subsequently revised to help prevent recurrence of this event.

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4 jy ' ? LICENSEE EVENT REPORT (LER) TEXT CONTINUATION b b f$3alem' Generating Station = DOCKET NUMBER LER NUMBER '

PAGE' LUnit 2' 5000311 90-024-00 2 of 4 w

.P_LANT AND__ SYSTEM INDE.N_TIFICET_I_ON1 Westinghouse - Pressurized 1 Water Reactor Energy: Industry Identification System (EIIS) codes are_ identified in i the text'as (xxl .{

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. IDENTIFICATION OF OCCURRENCE: l h  :

S Radioactive liquid release not conducted as required by Technical Specification Table 3.3.3.8 Table 3.3-12 due to personnel error, b . Event Date: 5/21/90-Report Date: 6/19/90 This report was initiated by Incident Report No.90-326.

~ CONDITIONS PRIOR TO OCCURRENCE:

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Mode 5_(Cold Shutdown)

DESCRIPTION OF OCCURRENCE:

On May 20, 1990 at 2123 hours0.0246 days <br />0.59 hours <br />0.00351 weeks <br />8.078015e-4 months <br />, release of the No. 22 CVCS Monitor

-Tank lWD) radioactive liquid contents was initiated. The release was

' terminated on May 21, 1990 at 0144 hours0.00167 days <br />0.04 hours <br />2.380952e-4 weeks <br />5.4792e-5 months <br />. During the post-release flush, a T-Handle instrument isolation valve, downstream of the 22WR165 valve, was discovered closed. The closure of the sample valve resulted in the isolation of the 2R18 Liquid Radwaste Effluent

'Line Monitor IILI. Had it been realized prior to'the release that the 3R18 monitor was " inoperable", either the monitor would have been made operable or Technical Specification 3.3.3.8 Table 3.3-12 Action 26 sample requirements would have been met.

Technical Specification Table 3.3.3.8 Table 3.3-12 Action 26 states:

1 "With the number of channels OPERABLE less than required by the Minimum Channels OPERABLE requirement,. effluent releases may I continue provided that prior to initiating a release:

At least two. independent samples are analyzed in accordance '

with Specification 4.11.1.1.1, and At least two technically qualified members of the Facility Staff independently verifiy the release rate calculations and discharge ~line valving; Otherwise, suspend release of radioactive effluents via this pathway."

, LICENSEE. EVENT REPORT-(LER) TEXT CONTINUATION

. Salem Generating Station DOCKET NUMBER LER NUMBER PAGE Unit 2 5000311 90-024-00 3 of 4 APPARENT CAUSE_OF OCCUR _RENCE.1 The root cause of this event has been attributed to personnel error.

The isolation of the 2R18 T-handle isolation valve occurred due to an error by Chemistry Department personnel.

After tbc addition of Hydrogen Peroxide to the CVCS Monitor Tank, which was utilized to neutralize Hydrazine contained within the CVCS Monitor Tank, the 2R-18 instrument isolation valve was indvertently left closed by the chemistry technician, which was not in compliance with the chemistry procedure.

Contributing to this event was procedural inadequacy. The valve alignment verification steps in the Operations procedure used to-control radioactive liquis releases (Operations Procedure II-11.3.2(b), " Release of Radioactive Liquid Waste To The Circulating Water System From 21 or 22 Monitor Tanks"), does not identify or require verification that the instrument isolation valve is open prior to a release.

ANALYSIS OF OCCURRENCE:

i r The release of radioactive liquid effluents is required to either be l '

constantly monitored (2R18) during the release or sampled and analyzed prior to release. This ensures that the release does not exceed applicable limits. As addressed by this report, the liquid release, initiating on May 20, 1990, was not constantly. monitored nor adequately sampled as per Technical Specification 3.3.3.8 Table l 3.3-12 Action 26. Therefore, this event is reportable to the Nuclear Regulatory Commission in accordance with Code of Federal Regulations 10CFR50. 73 (a) (2) (i) (B) due to noncompliance with the requirement of the aforementioned Technical Specification Action Statement.

Prior to the radioactive release a sample was taken of the~No. 22 CVCS Monitor Tank contents. This sample shows that the release of the contents was well within the allowable release limits for Salem Generating Station. Therefore, this event did not affect the health or safety of the public.

CORRECTIVE ACTION:

This event has been reviewed by Chemistry Department management. The Chemistry Department personnel involved in this event have been held accountable.

A critique of this event was conducted with applicable Chemistry Department personnel. The critique stressed the need to maintain attention to detail when performing work and the need for absolute procedural compliance.

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LICENSEE EVENT. REPORT'(LER) TEXT CONTINUATION Salem Generating. Station -DOCKET NUMBER LER NUMBER PAGE Unit 2 5000311 90-024-00 4 of 4 CORRECTIVE _ ACTION: (cont'dl The' instrument-isolation valve has been numbered, 22WR170 and will be added to the Tagging Request Information System (TRIS) data base.

The Operations Department release procedure will be revised to include verification that the instrument isolation valve is open prior to making a release. .These actions will be completed by July 1,.1990.

The SC.CH-AD.WL-0416(Q) chemistry procedure was reviewed. Based on the results of this review, the procedure has been revised to add a precautionary statement associated with the instrument isolation

. valve and to include a " check-off" to ensure correct valve positioning during the use of the procedure and upon completion of the procedure, i

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radioactive liquid contents was initiated. The release was terminated on May 21, 1990 at 0144 hours0.00167 days <br />0.04 hours <br />2.380952e-4 weeks <br />5.4792e-5 months <br />. During the post-release flush, a T-Handle instrument isolation valve was discovered closed resulting in the isolation of the 2R18 Liquid Radwaste Effluent Line Monitor. Had it been realized prior to the release that the 2R18 monitor was

" inoperable", either the monitor would have been made operable or l Technical Specification 3.3.3.8 Table 3.3-12 Action 26 sample  !

requirements would have been met. The root cause of this event has  !

been attributed to personnel error. The isolation of the 2R18 instrument isolation valve occurred due to an error by Chemistry l Department personnel after performing a chemical addition where this  !

valve was required to be isolated. Contributing to this event was l procedural inadequacy. The valve alignment verification steps, in the l Operations-procedure used to control radioactive liquid releases does I not identify-or require verification that the instrument isolation i valve is open prior to a release. The Chemistry Department personnel l involved in this event have been held accountable. A critique of this  !

event was conducted with all Chemistry Department personnel. The I instrument isolation valve has been numbered, 22WR170. The Operations Department release procedure will be revised to include verification that the instrument isolation valve is open prior to making a release. The chemistry addition procedure was reviewed and subsequently revised to help prevent recurrence of this event, l

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